Genitourinary Injuries Research Articles

Urologic Injury and Fistula After Hysterectomy for Benign Indications.

To explore the rates and risk factors for sustaining a genitourinary injury during hysterectomy for benign indications. In this population-based cohort study, all women who underwent hysterectomy for benign indications were identified from the Office of Statewide Health Planning and Development databases in California (2005-2011). Genitourinary injuries were further classified as identified at the time of hysterectomy, identified after the date of hysterectomy; or unidentified until a fistula developed. Of the 296,130 women undergoing hysterectomy for benign indications, there were 2,817 (1.0%) ureteral injuries, 2,058 (0.7%) bladder injuries and 834 (0.3%) genitourinary fistulas (80/834 of which developed after an injury repair). Diagnosis was delayed in 18.6% and 5.5% of ureteral and bladder injuries, respectively. Subsequent genitourinary fistula development was lower if the injury was identified immediately (compared with delayed) for both ureteral (0.7% vs 3.4% odds ratio [OR] 0.28; 95% CI 0.14-0.57) and bladder injuries (2.5% vs 6.5% OR 0.37; 95% CI 0.16-0.83). Indwelling ureteral stent placement alone was more successful in decreasing the risk of a second ureteral repair for immediately recognized ureteral injuries (99.0% vs 39.8% for delayed injuries). With multivariate adjustment, prolapse repair (OR 1.44, 95% CI 1.30-1.58), an incontinence procedure (OR 1.40, 95% CI 1.21-1.61), mesh augmented prolapse repair (OR 1.55, 95% CI 1.31-1.83), diagnosis of endometriosis (OR 1.46, 95% CI 1.36-1.56), and surgery at a facility in the bottom quartile of hysterectomy volume (OR 1.37, 95% CI 1.01-1.89) were all associated with an increased likelihood of a genitourinary injury. An exclusively vaginal (OR 0.56, 95% CI 0.53-0.64) or laparoscopic (OR 0.80, 95% CI 0.75-0.86) approach was associated with lower risk of a genitourinary injury as compared with an abdominal approach. Genitourinary injury occurs in 1.8% of hysterectomies for benign indications; immediate identification and repair is associated with a reduced risk of subsequent genitourinary fistula formation.

Robotic Urologic Surgery: Trends in Food and Drug Administration-Reported Adverse Events Over the Last Decade.

Background: The da Vinci Surgical System has led to a rapid growth in the volume of robot-assisted surgeries, with 877,000 surgeries performed in 2017. Despite the increasing prevalence of robotic urologic surgeries, few long-term studies exist that examine trends in reported adverse events (RAEs). We analyzed RAEs over the past decade. Materials and Methods: We extrapolated all entries from the Manufacturer and User Facility Device Experience (MAUDE) database with the manufacturer "Intuitive Surgical" from 2007 to 2017. Reports were analyzed for date and type of RAE (death, bodily injury, malfunction, and other). RAEs from urologic surgeries were analyzed further for specific information pertaining to death, bodily injury, and malfunction. Results: A total of 19,783 RAEs were analyzed. Instrument or robot malfunctions comprised the majority of RAEs (84.9%); bodily injuries comprised 8.2%. Death was the least common RAE (1.3%). RAEs for urologic robotic surgeries peaked in 2013 and 2014 and decreased since. A total of 69 (2.3%) deaths, 364 (12.2%) injuries, and 2544 (85.5%) instrument or robot malfunctions occurred. No reported deaths were attributed to system or mechanical malfunction, but rather to medical complications reported to be unrelated to surgery. The most common injuries were bowel (22.3%) and genitourinary (GU) (19.5%). Instrument malfunctions caused 16.8% of bodily injuries. Conclusions: RAEs for robotic urologic surgeries peaked in 2013 to 2014, and have decreased annually since. When malfunctions occurred, they did not result in death and infrequently resulted in bodily injury. Potential quality improvement targets include prevention of bowel and GU injuries through surgical coaching, and improved technology to prevent malfunction of the surgical system and instruments.

To Lower Risk for Fistula Formation After Hysterectomy, Be Proactive

Information about genitourinary injury after hysterectomy is limited; thus, investigators analyzed statewide California data from 2005 to 2011 in a

Incidence of erectile dysfunction in pelvic ring injuries: Study of 48 patients at the Antananarivo hospital, Madagascar

IntroductionPelvic fractures are responsible for genito-urinary injuries in 25% of cases. The objective of this study was to assess the severity and psychological impact of erectile dysfunction in patients with pelvic ring fractures. HypothesisUnstable pelvic fractures are associated with erectile dysfunction and depression. Patients and methodWe retrospectively reviewed consecutive patients older than 18 years who were admitted to the orthopaedic and trauma surgery department of the Antananarivo university hospital, Madagascar, over a 3-year period (2014–2016) for pelvic ring fractures. Erectile function was assessed using the 5-item International Index of Erectile Function questionnaire (IIEF-5) and mood using the Major Depression Inventory (MDI). All patients were invited to attend a visit to complete both questionnaires. ResultsThe study included 48 patients with a mean age of 39 years (range, 18–82 years) and a mean follow-up of 12 months. The fracture was due to a traffic accident in 81.2% of patients and occurred as one of multiple injuries in 22.9% of patients. The fracture was stable in 34 (70.8%) patients (type A1, 16 patients; type A2, 18 patients) and unstable in 14 (29.5%) patients (type B, 9 patients; type C, 5 patients). Erectile dysfunction was found in 16 (33.3%) patients and was severe in 6, moderate in 4, and mild in 6. Erectile dysfunction was more common in the patients who had type C fractures. Depression was associated with severe erectile dysfunction. ConclusionErectile function should be assessed in the medium and long term in patients with pelvic ring fractures. If left untreated, erectile dysfunction may lead to depression in these often young patients. Level of evidenceIV, retrospective observational study.

Urinary Tract Infections after Combat-Related Genitourinary Trauma.

Background: We examined clinical outcomes among combat casualties with genitourinary injuries after blast trauma. Methods: Characteristics, clinical care, urologic complications, and infections for subjects enrolled in the Trauma Infectious Disease Outcomes Study (TIDOS) were collected from Department of Defense (DOD) and Department of Veterans Affairs (VA) sources. Logistic regression identified predictors for urinary tract infections (UTIs) after genitourinary trauma. Results: Among 530 TIDOS enrollees who entered VA care, 89 (17%) sustained genitourinary trauma. The majority of subjects (93%) were injured via a blast and 27% had a dismounted complex blast injury (DCBI). Sexual dysfunction was reported with 36% of subjects, whereas 14% had urinary retention/incontinence and 8% had urethral stricture. Urologic complications were comparable between patients with and without DCBIs. Nineteen (21%) subjects had one or more UTI with a total of 40 unique UTI events (25% during initial hospitalization and 75% during subsequent DOD or VA care). The UTI incidence rate was 0.89 per patient-year during initial hospitalization, 0.05 per patient-year during DOD follow-up, and 0.07 per patient-year during VA healthcare. Subjects with UTIs had a higher proportion of bladder injury (53% vs. 13%; p < 0.001), posterior urethral injury (26% vs. 1%; p = 0.001), pelvic fracture (47% vs. 4%; p < 0.001), soft-tissue infection of the pelvis/hip (37% vs. 4%; p = 0.001), urinary catheterization (47% vs. 11%; p < 0.001), urinary retention or incontinence (42% vs. 6%; p < 0.001), and stricture (26% vs. 3%; p = 0.004) compared with patients with genitourinary trauma and no UTI. Independent UTI risk factors were occurrence of a soft-tissue infection at the pelvis/hip, trauma to the urinary tract, and transtibial amputation. Conclusions: Among combat casualties with genitourinary trauma, UTIs are a common complication, particularly with severe blast injury and urologic sequelae. Episodes of UTIs typically occur early after the initial injury while in DOD care, however, recurrent infections may continue into long-term VA care.

Imaging of Traumatic Injuries to the Male Lower Genitourinary Organs and Impact on Surgical Management

Genitourinary trauma occurs in 10% of all patients with abdominal trauma, and it is more common in men due to the external location of the male genital organs and longer length of the male urethra, which make them more susceptible to traumatic injuries.1 Concomitant injuries are not uncommon and may distract from or delay the diagnosis of genitourinary injuries, potentially leading to complications, loss of function, and irreversible damage.1 Radiologists play a key role in diagnosing male genitourinary injuries to expedite appropriate surgical management.

Urologic Injury and Fistula Following Hysterectomy for Benign Indications [37S

INTRODUCTION: Genitourinary injury is a rare but devastating complication following hysterectomy. Literature regarding this topic is limited, so we explored genitourinary injury rates (and risk factors for injury) in a population based dataset with long term follow-up. METHODS: All women who underwent a hysterectomy for benign indications were identified using data from the Office of Statewide Health Planning and Development in California from 2005-2011. Cases of genitourinary injury were identified (either identified intraoperatively or missed). RESULTS: Of the 296,130 women who underwent hysterectomy, 5,455 (1.8%) suffered at least one urologic injury: 2,817 (1.0%) ureteral, 2,058 (0.70%) bladder and 831 (0.3%) fistulas. Sustaining an injury increased the risk of future fistula (1.1% and 2.7% versus 0.3%, p<0.001), however immediate identification and repair of the injury decreased this risk for both ureteral (0.7% versus 3.4%, p<0.001) and bladder (2.5% versus 6.5%, p<0.001) injuries. Multivariate modeling revealed that concomitant POP repair (OR 1.12, p=0.019), a diagnosis of endometriosis (OR 1.40 p<0.001) and surgery at a facility in the bottom 25% of hysterectomy volume (OR 1.37, p=0.049) were associated with increased likelihood of injury, while vaginal (OR 0.85, p=<0.001) or laparoscopic (OR 0.81, p<0.001) approach and diagnosis of endometrial hyperplasia/abnormal uterine bleeding (OR 0.91, p=0.004) were associated with a decreased risk of injury. CONCLUSION: Benign hysterectomy carries a ∼1.8% risk of genitourinary injury. Although injury increases the chance of fistula formation, recognizing the injury immediately reduces this risk. We identify several factors that are associated with injury, providing insight where a higher index of suspicion might be held.

Cystoscopy at the Time of Hysterectomy for Benign Indications and Delayed Lower Genitourinary Tract Injury.

To compare the rate of delayed 30-day lower genitourinary tract injury in women who underwent cystoscopy at the time of hysterectomy for benign indications to those who did not. This was a retrospective cohort study of patients who underwent hysterectomy without a concomitant procedure for prolapse or incontinence for benign pathology with a general obstetrician-gynecologist (ob-gyn) recorded in the National Surgical Quality Improvement Program targeted hysterectomy file between 2015 and 2017. The primary outcome was a delayed lower genitourinary tract injury in the 30 days after hysterectomy. Secondary outcomes included urinary tract infection and operative time. The exposure of interest was cystoscopy at the time of hysterectomy. Stratified analysis was performed by route of surgery. Bivariable tests were used to examine associations. We identified 39,529 women who underwent hysterectomy for benign indications with a general ob-gyn. Surgical approach was open (26%), laparoscopic or robotic assisted laparoscopic (46%), and vaginal or vaginally assisted (28%). Overall, 25% of women underwent cystoscopy at the time of hysterectomy; cystoscopy was more commonly performed in laparoscopic or robotic (32%) and vaginal hysterectomy (25%) as compared with open hysterectomy (11%) (P<.001). There was no difference in delayed lower genitourinary tract injury between patients who underwent cystoscopy at time of hysterectomy compared with those who did not undergo cystoscopy (0.27% vs 0.24%, P=.64). Patients who underwent cystoscopy were more likely to be diagnosed with a urinary tract infection (2.6% vs 2.0%, RR 1.27 95% CI 1.09-1.47). Median operative time was increased by 17 minutes in cases where cystoscopy was performed (132 vs 115 minutes, P<.001). Cystoscopy at the time of hysterectomy for benign indications does not result in a lower rate of 30-day delayed lower genitourinary tract injury compared with no cystoscopy.

MP02-16 UROLOGIC INJURY AND FISTULA FOLLOWING HYSTERECTOMY FOR BENIGN INDICATIONS

INTRODUCTION AND OBJECTIVES:Genitourinary injury and vaginal fistula formation are rare but devastating complications following hysterectomy. The literature regarding this topic is limited and gene...

Blunt trauma pelvic fracture-associated genitourinary and concomitant lower gastrointestinal injury: incidence, morbidity, and mortality.

Limited data exist on the characteristics, risk factors, and management of blunt trauma pelvic fractures causing genitourinary (GU) and lower gastrointestinal (GI) injury. We sought to determine these parameters and elucidate independent risk factors. The National Trauma Data Bank for years 2010-2014 was queried for pelvic fractures by ICD-9-CM codes. Exclusion criteria included age ≤ 17years, penetrating injury, or incomplete records. Patients were divided into three cohorts: pelvic fracture, pelvic fracture with GU injury, and pelvic fracture with GU and GI injury. Between-group comparisons were made using stratified analysis. Multivariable logistic regression was used to determine independent risk factors for concomitant GI injury. In total, 180,931 pelvic fractures were found, 3.3% had GU, and 0.15% had GU and GI injury. Most common mechanism was vehicular collision. Injury severity score, pelvic AIS, and mortality were higher with combined injury (p < 0.001), leading to longer hospital and ICU stays and ventilator days (p < 0.001) with more frequent discharges to acute rehabilitation (p < 0.01). Surgical management of concomitant injuries involved both urinary (62%) and rectal repairs (81%) or diversions (29% and 46%, respectively). Male gender (OR = 2.42), disruption of the pelvic circle (OR = 6.04), pubis fracture (OR = 2.07), innominate fracture (OR = 1.84), and SBP < 90mmgh (OR = 1.59) were the strongest independent predictors of combined injury (p < 0.01). Pelvic fractures with lower GU and GI injury represent < 1% of pelvic fractures. They are associated with more severe injuries and increased hospital resource utilization. Strongest independent predictors are disruption of the pelvic circle, male gender, innominate fracture, and SBP < 90mm Hg.

Scrotal trauma: A case report and review of the literature.

Genitourinary (GU) injury is present in approximately 10% of cases of abdominal trauma.1 Of those GU injuries, up to 67% involve the external genitalia.2,3 GU trauma is more common in males, especially in the instance of genital injury. This increased incidence in males is secondary to both anatomical considerations and increased participation in activities such as contact sports, violent interaction, and war activities.2 The lower urinary tract is susceptible to traumatic injury by way of various mechanisms. These injuries, and their sequelae, can affect patients of any age or background. Though lower urinary tract trauma rarely results in life-threating pathology, appropriate management of these injuries is pivotal in decreasing long-term morbidity.4 Although the external genitalia in males are at high risk of injury in trauma because of their extracorporeal location, the scrotum and testes are relatively well-protected from severe damage for the following reasons: 1) the testes are inherently mobile within the scrotum; 2) the scrotal skin provides reasonable elasticity allowing for internal structures to slip away from the point of contact in blunt trauma; 3) the cremasteric reflex offers a protective reflex mechanism; and 4) the tunica albuginea serves as a tough fibrous physical defense with its tensile strength.4–6 Resultantly, the incidence of scrotal or testicular injury in a trauma activation is generally considered to be less than one percent. However, the associated morbidity to the patient (including psychological effects of testicular injury or loss) and health system costs associated with these injuries warrant special attention.5,7–9 In general, there are two broad domains to consider when evaluating scrotal trauma: blunt vs. penetrating injury. Historically, blunt injury has been thought to comprise the significant majority (i.e., 75–80%) of genital trauma.2,4 A recent analysis of the National Trauma Data Bank in the U.S. described a more balanced distribution of penetrating vs. blunt scrotal trauma, with both representing nearly half of all injuries.5 However, this significant difference in reported mechanism may be attributable to input biases and geopolitical determinants (e.g., increased incidence of gunshot wound [penetrating] injuries in the U.S. compared to other nations). The importance of categorizing these these types of injuries into broad classes lies in the special diagnostic and management considerations for each type of injury (Fig. 2). For example, while just 1.5% of blunt testicular injury involves the gonads bilaterally, approximately 30% of penetrating scrotal injury will involve both testes. Additionally, penetrating injury occurs with associated injuries in approximately 70% of patients, decreasing the threshold of suspicion of damage to neighboring structures, such as the penis, bladder, urethra, and femoral vessels.2,4 However, workup for associated injury should not be neglected in the setting of blunt trauma either, and nearby structures should be appropriately investigated when clinical suspicion is present (e.g., blood at the urethral meatus suggesting urethral injury).4 Other domains of scrotal trauma, including thermal and degloving/scrotal wall avulsion injuries, are described in the literature as well and will be discussed here briefly. Open in a separate window Fig. 2 Simplified diagnostic and management pathway in blunt and penetrating scrotal trauma.

Abdominal Trauma and Complications

The abdomen, including pelvis, is injured in 10 to 15% of significantly injured patients: 80% by blunt and 20% by penetrating mechanisms. Abdominal injuries can be subtle and hence missed. The majority of injuries, if detected early, can be treated, and hence, delay in diagnosis or underappreciation of the severity of intra-abdominal injury is responsible for significant preventable morbidity and even mortality. The initial management is the same as any trauma patient, with the greatest threats to life addressed first. If the patient is in shock and the source is intra-abdominal, urgent laparotomy is indicated along with damage control resuscitation. If the patient remains in shock in the operating room, abbreviated damage control laparotomy should be pursued. In stable patients with penetrating mechanism, if the penetration extends into the peritoneal cavity, operative exploration to identify and address any injury is the safest approach; however, more selective approaches are increasingly being pursued. In stable patients with blunt mechanism, a thorough evaluation, usually including IV contrast-enhanced CT (CECT) is pursued to diagnose, and equally importantly, exclude intra-abdominal injury. High-quality IV CECT has a very high negative predictive value for intra-abdominal injuries. In stable patients, injuries to spleen, liver, and kidney, irrespective of grade, are managed nonoperatively with or without angioembolization. Lower-grade pancreatic injuries are managed nonoperatively or with drainage, whereas higher-grade injuries (involving major ducts) usually require resection. Majority of gastrointestinal hollow viscus injuries are managed with repair, resection with anastomosis or diversion. Delays as short as 8 hours in definitive management of such injuries increase morbidity and mortality. Intra and retro peritoneal genitourinary injuries are repaired and extraperitoneal ones are managed without surgery. Retroperitoneal hematomas are managed based on mechanism, stability, and location. Abdominal trauma is associated with a host of complications that need to be detected early and managed appropriately to prevent delayed morbidity and mortality. This review contains 5 figures, 6 tables, and 60 references. Key Words: abdomen, complications, damage control, diaphragm, hollow viscus, trauma, solid organ, retroperitoneum

Long-Term Patient-Reported Functional Outcome of Polytraumatized Patients With Operatively Treated Pelvic Fractures.

To report the long-term functional outcome of a cohort of patients with operatively treated unstable pelvic fractures using validated patient-reported outcome measures. Long-term observational study using prospective and retrospective data. Tertiary referral pelvic trauma center, Bristol, United Kingdom. Seventy-four polytraumatized patients with operatively treated unstable pelvic ring injuries (50 OTA/AO type B and 24 OTA/AO type C, mean Injury Severity Score 17) treated between 1994 and 2005. Sixty-four (86%) patients were treated with internal fixation. The remaining 10 patients (14%) were treated with either combined percutaneous posterior fixation and anterior external fixation or external fixation in isolation. Patient-reported functional outcome. Short Form-36, with UK norm-based comparator scores and EQ-5D-3L. Patients were between 11 and 22 years after injury (mean 15 years). We found no significant association between fracture classification and outcome score, but compared with age- and sex-matched scores for a UK population, differences were statistically significant in 3 of the 8 domains of health: physical function (P = 0.04), bodily pain (P = 0.001), and vitality (P = 0.001). The level of disability remained constant for these patients compared with their patient-reported outcome measure scores reported 8 years previously. Patients who sustain an unstable pelvic fracture continue to have significant functional limitations compared with an uninjured population. These changes were not found to be related to age, injury pattern, genitourinary injury, or neurological injury. Functional outcome scores did not change over the 2 long-term time points. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Management von Harnleiterverletzungen

Ureteral injuries account for less than 3% of genitourinary injuries. Most of them are caused iatrogenically during abdominal surgery. The symptoms are often non-specific and do not aid in diagnosis. The later the injury is detected, the more often complications occur. Therefore, in such situations it is important to consider the possibility of ureteral injury and initiate further diagnostic steps as soon as possible. Avariety of diagnostic tests are available. In addition to the direct inspection of the ureters and retrograde ureteropyelography, computed tomography (CT) urography is routinely used. Based on the time of diagnosis as well as the extent and the localization of the injury, the further procedure can be determined. For minor injuries, the insertion of a ureteral splint is usually the treatment of choice. In the case of higher grade damage, operative reconstruction by one of several possible surgical procedures is indicated.

The relationship between injury mechanism and sexual dysfunction in surgically treated pelvic fractures.

The aim of the study was to identify the incidence of new sexual dysfunction reported by the patient in surgical treatment of pelvic ring injuries, and to describe the relationship between new sexual dysfunction and type of fracture. Ninety-five patients who were operated for pelvic fracture were included in the study. Patients were evaluated according to age, gender, marital status, body mass index, trauma mechanism, fracture classification, genitourinary injury, accompanying injury, injury severity score, surgical technique, fixation material, duration of operation, functional outcomes, blood loss, complications, and sexual dysfunction. Functional outcomes were assessed with Female Sexual Functioning Index (FSFI), International Index of Erectile Function-5 (IIEF5), Arizona Sexual Experience Scale (ASEX), and Modified Majeed's pelvic outcomes grading scale (MPS). Genitourinary symptoms were erectile dysfunction (ED) in 13 men, ejaculatory dysfunction in 9 men, and dyspareunia in 23 women. Urethral stricture developed in 4 males and 1 female with the urethral injury. FSFI score, ASEX score, and MPS score showed the statistically significant difference between the fracture types (p = 0.021, p = 0.032 and p = 0.020, respectively). There were no significant difference between fracture types in terms of the IIEF5 score, and no significant relationship between fracture type and ED development (p = 0.141). Anteroposterior compression (APC) is the most common cause of sexual dysfunction in both sexes, independent of surgery. In addition, the most common cause of ED in men is vertical shear (VS). Especially patients with APC and VS injuries should be multidisciplinary evaluated with gynecology, urology, and psychiatry departments.

Urethral Trauma Following Pelvic Fracture From Horseback Saddle Horn Injury Versus Other Mechanisms of Pelvic Trauma

To examine the rate of urethral trauma and pubic symphysis diastasis in saddle horn injury, which occurs when horseback riders are bucked into the air and land with their perineum striking the rigid saddle horn, compared to pelvic fracture from other mechanisms. A retrospective review was performed of male patients presenting to our level-1 trauma center with pelvic ring fractures between January 1, 2001 and December 30, 2016. Demographics, injury severity score, mechanism of injury (saddle horn vs other), pubic symphysis diastasis, and lower genitourinary (GU) injuries (bladder and urethra) were identified in the trauma registry. Chart review confirmed accuracy of lower GU trauma. A total of 1195 males presented with pelvic ring fractures, average age 43 years (SD 19 years). Of these, 87 of 1195 (7%) presented with lower GU injuries. Saddle horn injuries had a higher rate of lower GU injuries, 12/60 (20%) versus 75 of 1135 (7%) [P = .001]. In those with lower GU injuries, 47 of 87 (54%) had urethral injury. The rate of urethral injury was significantly higher in the saddle horn cohort, 10 of 12 (83%) versus 37 of 75 (49%) [P = .03]. Furthermore, rate of pubic symphysis diastasis was higher amongst saddle horn injuries, 12 of 12 (100%) versus other mechanisms 39 of 75 (52%) [P = .001]. We found that urethral injury and pubic symphysis diastasis were higher in patients with saddle horn injury compared to other mechanisms of pelvic ring disruption. Clinicians should be aware of these associations when treating pelvic fracture following equestrian injuries.

Bladder and ureteral injuries during benign hysterectomy: an observational cohort analysis in New York State.

Hysterectomy (Hys) is the most common non-urologic surgery associated with iatrogenic genitourinary (GU) injury. We present the largest known population-based evaluation of GU injury related to benign Hys. The New York Statewide Planning and Research Cooperative System (SPARCS) was queried by ICD-9 and CPT codes. SPARCS for women from 1995 to 2014, who underwent laparoscopic or robotic Hys (minimally invasive surgery = MIS), abdominal Hys (AH), and vaginal Hys (VH) for benign diagnoses. Bladder and ureteral repairs were captured based on the procedure codes. Codes for ureteroneocystotomy (UNC) were compared to any other ureteral repairs, to elucidate injury patterns. Statistical analysis was conducted using Chi squared test, ANOVA, Mann-Whitney test and Poisson Regression and multivariable analysis were performed. 516,340 women underwent Hys for a benign etiology. 69% were AH, 25% VH, and 6% were MIS. 7490 patients (1.45%) had a concomitant GU injury. Compared to VH, MIS and AH were associated with greater odds of bladder and ureteral injury (p < 0.001). MIS and AH, compared to VH, were associated with reduced odds of UNC compared to complex reconstruction (OR 0.27, p < 0.001 and OR 0.12, p < 0.00, respectively). The injured cohort had higher total mean charges ($29,889 vs $15,808) and length of hospitalization (6.32 vs 3.56days) (p < 0.001). Bladder and ureteral injuries during hysterectomy are uncommon in contemporary practice and are lower than historical rates. GU injury increases hospitalization cost. VH is associated with the lowest rate of GU injury, and thus appears to be a valuable approach, when feasible.

BLADDER OUTLET OBSTRUCTION LEADING TO URINOTHORAX

SESSION TITLE: Disorders of the Pleura 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Urinothorax is the presence of urine in the pleural space as a result of genitourinary (GU) trauma or obstructive uropathy. Injury in the GU tract results in urine extravasation into the peritoneal or retroperitoneal space, which then enters the pleural space via the diaphragm or lymphatics. Pleural fluid analysis greatly aids in the diagnosis. Dyspnea is often the presenting symptom. Less than seventy cases of urinothorax have been identified in the literature. CASE PRESENTATION: A 78-year old male presented with fatigue, dyspnea, suprapubic pain, and urinary incontinence for the past two weeks. Routine workup revealed AKI and hyperkalemia. The patient had a history of CVA, hypertension, hyperlipidemia and chronic kidney disease. Computed tomography (CT) of abdomen/pelvis revealed an enlarged prostate with bladder outlet obstruction and severe hydroureteronephrosis. Additionally, a large right sided pleural effusion with near collapse of the right lower lobe was noted [Figure 1]. A thoracentesis was performed and 2020 mL of simple, serous fluid was drained. The transudative fluid had a pH of 7.2, total fluid protein < 1.0 and fluid to serum creatinine ratio >1.0, highly suggestive of urinothorax. His dyspnea resolved after thoracentesis. He ultimately required bilateral percutaneous nephrostomy tubes with improvement in his renal function and no recurrence of urinothorax or other pleural effusion as seen on subsequent imaging. Given his known obstructive uropathy, no further workup was indicated for etiology of urinothorax. DISCUSSION: Urinothorax is a rare cause of pleural effusions that is caused by GU trauma, including iatrogenic instrumentation or transplant, or obstructive uropathy, including mechanical obstruction or bladder outlet obstruction. In both etiologies, the mechanism involves high pressures that result in translocation of urine into spaces that ultimately connect with the pleural space. Diagnosis involves identifying a pleural effusion and subsequently testing pleural fluid via thoracentesis. This rare and under diagnosed condition presents as the only transudative pleural effusion with pH <7.40. Other abnormal labs include a pleural fluid to serum creatinine ratio >1.0 and/or elevated LDH in pleural fluid. The fluid to serum creatinine ratio is the most specific feature of urinothorax. CT or ultrasound imaging can help discover the cause. Although there is an association with nephrostomy, our case was due to obstructive uropathy as it was diagnosed prior to intervention. CONCLUSIONS: Urinothorax is a rare condition that can result from abdominal trauma, genitourinary tract injury or obstructive uropathy. Recognition of this rare entity is important to allow for timely alleviation of obstruction, relieve symptoms, and prevent recurrence; as was the case with our patient. Reference #1: Austin, Adam & Navin Jogani, Sidharth & Bradley Brasher, Paul & Gupta Argula, Rahul & Huggins, John & Chopra, Amit. (2017). The Urinothorax: A Comprehensive Review with Case Series. The American Journal of the Medical Sciences. 354. 44-53. Reference #2: Toubes ME, Lama A, Ferreiro L, et al. Urinothorax: a systematic review. Journal of Thoracic Disease. 2017;9(5):1209-1218. https://doi.org/10.21037/jtd.2017.04.22. DISCLOSURES: No relevant relationships by Michael Bergman, source=Web Response No relevant relationships by Ryan Richard, source=Web Response No relevant relationships by Jigna Solanki, source=Web Response

Evaluation of current health expenditures of adolescents and its financial burdens in China: a quantitative analysis

BackgroundAfter being neglected for decades, increasing international attention has been focused on adolescent health. Data for adolescent health financing is needed to inform policies to allocate adequate resources, set strategic priorities, and ensure sustainable funding for adolescent health programmes and strategies. To prepare and inform national adolescent health and development strategies in China, we aimed to quantify and describe adolescents' current health expenditures, and to determine the financial burden to provide a framework for policy discussion. MethodsWe did a quantitative analysis of current health expenditures of adolescents in China. We collected primary data for adolescent health expenditures and service provision from ad-hoc institution surveys, and secondary data, such as national aggregate expenditures and government programmes, over 2014. On the basis of the principles and definitions of the System of Health Accounts 2011, we used a top-down approach to estimate adolescent health expenditures in China, and examined it by multiple dimensions, including financing schemes, health providers, health functions, and diseases that were based on primary diagnosis. FindingsThe adolescents' current health expenditures amounted to CNY82·1 billion, or 2·6% of the current health expenditures for the whole population in China. In per capita terms, adolescent health expenditures were CNY525, which were less than the average amount of the whole population (CNY2349). The expenditures mainly occurred in hospitals (56·7%), whereas primary health-care institutions shared a smaller portion (10·5%). Curative care represented the largest share of the total adolescent health expenditures, approximately 73·1% of the total expenditures. Adolescent health expenditures was mainly financed by household out-of-pocket payment, accounting for 57·9%. Respiratory, digestive, and genitourinary diseases, injury and poisoning, and neoplasms accounted for 59·8% of adolescent curative care expenditures. InterpretationMedical financing burden on households was substantial; allocation of medical resources remained irrational. Health interventions targeting key diseases need to be intensified to avoid or decrease the occurrence of related health expenditures in adolescents. FundingHong Kong Committee for UNICEF.

Combat-related genitourinary (GU) injury: implications for reproductive quality of life

Combat-related genitourinary (GU) injury: implications for reproductive quality of life